Assessment of Nutritional Status Nutritional status is the current body status, of a person or a population group, related to their state of nourishment (the consumption and utilization of nutrients). The nutritional status is determined by a complex interaction between internal/constitutional factors and external environmental factors: Internal or constitutional factors like: age, sex, nutrition, behavior, physical activity and diseases. External environmental factors like: food safety, cultural, social and economic circumstances. The complex interaction between internal or constitutional factors and external environmental factorsAn ideal nutritional status occurs when the supply of nutrients conforms to the nutritional requirements or needs
Diets are rated in quality according to the balance of nutrients they provide, and not solely on the type of food eaten or the amount of caloric intake. FOOD GUIDEPYRAMID People can have an optimal nutritional status or they can be under-, over- and/or malnourished The nutritional status of an individual has consequences:o An optimal nutritional status is a powerful factor for health and well being . It is a major, modifiable and powerful element in promoting health, preventing and treating diseases and improving the quality of life.o Malnutrition may increase risk of (susceptibility to) infection and chronic diseases : undernutrition may lead to increased infections and decreases in physical and mental development, and overnutrition may lead to obesity as well as to metabolic syndrome or type 2 diabetes.
Purpose of nutritional assessment 1. Identify individuals or population groups at risk of becoming malnourished 2. Identify individuals or population groups who are malnourished 3. To develop health care programs that meet the community needs which are defined by the assessment 4. To measure the effectiveness of the nutritional programs & interventions once initiated
Methods of Nutritional Assessment Nutrition is assessed by two methods; direct and indirect . The direct methods deal with the individual and measure objective criteria, while indirect methods use community indices that reflect the community nutritional status/needs.Indirect Methods of Nutritional Assessment Ecological variables including agricultural crops production Economic factors e.g. household income, per capita income, population density, food availability and prices Cultural and social habits Vital health statistics: morbidity, mortality and other health indicators e.g., infant and under- fives mortality, Utilization of maternal and child health care services, fertility indices and sanitary conditions
Direct Methods of Nutritional Assessment These are summarized as ABCD Anthropometric methods C linical methods D ietary evaluation methods B iochemical, laboratory methodsAnthropometric Methods Anthropometry is the measurement of body height, weight & proportions. It is an essential component of clinical examination of infants, children & pregnant women. It is used to evaluate both under & over nutrition. The measured values reflects the current nutritional status & don’t differentiate between acute & chronic changes . Other anthropometric Measurements Mid-arm circumference Skin fold thickness Head circumference Head/chest ratio Hip/waist ratio Anthropometry for children Accurate measurement of height and weight is essential. The results can then be used to evaluate the physical growth of the child. For growth monitoring the data are plotted on growth charts over a period of time that is enough to calculate growth velocity, which can then be compared to international standards Measurements for adults Height: The subject stands erect & bare footed on a stadiometer with a movable head piece. The head piece is leveled with skull vault & height is recorded to the nearest 0.5 cm. WEIGHT MEASUREMENT Use a regularly calibrated electronic or balanced-beam scale. Spring scales are less reliable. Weigh in light clothes, no shoes Read to the nearest 100 gm (0.1kg)
Nutritional Indices in Adults The international standard for assessing body size in adults is the body mass index (BMI). BMI is computed using the following formula: BMI = Weight (kg)/ Height (m²) Evidence shows that high BMI (obesity level) is associated with type 2 diabetes & high risk of cardiovascular morbidity & mortality BMI (WHO - Classification) BMI < 18.5 = Under Weight BMI 18.5-24.5= Healthy weight range BMI 25-30 = Overweight (grade 1obesity) BMI >30-40 = Obese (grade 2 obesity) BMI >40 =Very obese (morbid orgrade 3 obesity)Waist/Hip Ratio Waist circumference is measured at the level of the umbilicus to the nearest 0.5 cm. The subject stands erect with relaxed abdominal muscles, arms at the side, and feet together. The measurement should be taken at the end of a normal expiration.Waist circumference Waist circumference predicts mortality better than any other anthropometric measurement. It has been proposed that waist measurement alone can be used to assess obesity, and two levels of risk have been identifiedMALES FEMALE LEVEL 1 > 94cm > 80cm LEVEL2 > 102cm > 88cm Level 1 is the maximum acceptable waist circumference irrespective of the adult age and there should be no further weight gain. Level 2 denotes obesity and requires weight management to reduce the risk of type 2 diabetes & CVS complications.
Hip Circumference Is measured at the point of greatest circumference around hips & buttocks to the nearest 0.5 cm. The subject should be standing and the measurer should squat beside him. Both measurement should taken with a flexible, non-stretchable tape in close contact with the skin, but without indenting the soft tissue.Interpretation ofWaist / Hip ratio WHR High risk WHR= >0.80 for females &>0.95 for males i.e. waist measurement >80% of hip measurement for women and >95% for men indicates central (upper body) obesity and is considered high risk for diabetes & CVS disorders. A WHR below these cut-off levels is considered low risk.Body Mass Index for Children and Teens The criteria used to interpret the meaning of the BMI number for children and teens are different from those used for adults. For children and teens, BMI age- and sex-specific percentiles are used for two reasons: The amount of body fat changes with age. The amount of body fat differs between girls and boys
ADVANTAGES OF ANTHROPOMETRY Objective with high specificity & sensitivity Measures many variables of nutritional significance (Ht, Wt, MAC, HC, skin fold thickness, waist & hip ratio & BMI). Readings are numerical & gradable on standard growth charts Readings are reproducible. Non-expensive & need minimal trainingLimitations of Anthropometry Inter-observers errors in measurement Limited nutritional diagnosis Problems with reference standards, i.e. local versus international standards. Arbitrary statistical cut-off levels for what considered as abnormal values.
Biochemical assessmentInitial Laboratory Assessment Hemoglobin estimation is the most important test, & useful index of the overall state of nutrition. Beside anemia it also tells about protein & trace element nutrition. Stool examination for the presence of ova and/or intestinal parasites Urine dipstick & microscopy for albumin, sugar and bloodSpecific Lab Tests Measurement of individual nutrient in body fluids (e.g. serum retinol, serum iron, urinary iodine, vitamin D) Detection of abnormal amount of metabolites in the urine (e.g. urinary creatinine/hydroxyproline ratio)
Analysis of hair, nails & skin for micro-nutrients.Advantages of Biochemical Method It is useful in detecting early changes in body metabolism & nutrition before the appearance of overt clinical signs. It is precise, accurate and reproducible. Useful to validate data obtained from dietary methods e.g. comparing salt intake with 24- hour urinary excretion.Limitations of Biochemical Method Time consuming Expensive They cannot be applied on large scale Needs trained personnel & facilities
CLINICAL ASSESSMENT Intro It is an essential features of all nutritional surveys It is the simplest & most practical method of ascertaining the nutritional status of a group of individuals It utilizes a number of physical signs, (specific &non specific), that are known to be associated with malnutrition and deficiency of vitamins & micronutrients. Good nutritional history should be obtained General clinical examination, with special attention to organs like hair, angles of the mouth, gums, nails, skin, eyes, tongue, muscles, bones, & thyroid gland. Detection of relevant signs helps in establishing the nutritional diagnosis Examples of illnesses caused by improper nutrient consumption 1. Vitamin-A deficiency i. Xerophthalmia ii. Bitot’s spot 2. Vitamin A Deficiency 3. Beriberi Vitamin B1 (Thiamine) deficiency 4. Vitamin B2 Deficiency (Ariboflavinosis) 5. Pellagra Vitamin B3 ( Niacin) Deficiency Clinical-4 D’s: Dermatitis, Diarrhea, Dementia, Death 6. Scurvy (Vitamin C Deficiency) 7. Rickets (Vitamin D deficiency) 8. Goitre (Iodine deficiency disorder) 9. Marasmus Kwashiorkor Protein energy malnutrition 10. Protein-energy malnutrition (PEM) Marasmus Kwashiorkor
Clinical signs of nutritional deficiency from ppt
ADVANTAGES Fast & Easy to perform Inexpensive Non-invasiveLIMITATIONS Did not detect early cases
DIETARY ASSESSMENT Nutritional intake of humans is assessed by five different methods. These are: 1. 24 hours dietary recall 2. Food frequency questionnaire 3. Dietary history since early life 4. Food dairy technique 5. Observed food consumption 24 Hours Dietary Recall A trained interviewer asks the subject to recall all food & drink taken in the previous 24 hours. It is quick, easy, & depends on short-term memory, but may not be truly representative of the person’s usual intake Food Frequency Questionnaire In this method the subject is given a list of around 100 food items to indicate his or her intake (frequency & quantity) per day, per week & per month. inexpensive, more representative & easy to use. Limitations: long Questionnaire Errors with estimating serving size. Needs updating with new commercial food products to keep pace with changing dietary habits. DIETARY HISTORY It is an accurate method for assessing the nutritional status. The information should be collected by a trained interviewer. Details about usual intake, types, amount, frequency & timing needs to be obtained. Cross-checking to verify data is important. FOOD diary Food intake (types & amounts) should be recorded by the subject at the time of consumption. The length of the collection period range between 1-7 days. Reliable but difficult to maintain.
Observed Food Consumption The most unused method in clinical practice, but it is recommended for research purposes. The meal eaten by the individual is weighed and contents are exactly calculated. The method is characterized by having a high degree of accuracy but expensive & needs time & efforts.Interpretation of Dietary Data1. Qualitative Method using the food pyramid & the basic food groups method. Different nutrients are classified into 5 groups (fat & oils, bread & cereals, milk products, meat-fish-poultry, vegetables & fruits) determine the number of serving from each group & compare it with minimum requirement. Interpretation of Dietary Data/22. Quantitative Method The amount of energy & specific nutrients in each food consumed can be calculated using food composition tables & then compare it with the recommended daily intake. Evaluation by this method is expensive & time consuming, unless computing facilities are available.
Bibliography 1. Biochemicalmethods in nutritional assessment By H. F. WOODS, UniversityDepartment of Therapeutics, TheRoyal Hallamshire Hospital,Shefield 2. What is Subjective Global Assessment of Nutritional Status? ALLAN S. DETSKY, M.D., PH.D., JOHN R. MCLAUGHLIN, M.SC., JEFFREY P. BAKER, M.D., NANCY JOHNSTON, B.SC.N., SCOTT WHITTAKER, M.D., RENA A. MENDELSON, SC.D., AND KHURSHEED N. JEEJEEBHOY, M.B.B.S 3. Nutritional Status Assessment Dr RajkumarPatil Assistant prof., community Medicine A V Medical college, Pondicherry 4. Assessment Of Nutritional Status Dr.SohaRashed Professor of Community Medicine Alexandria Faculty of Medicine 5. ASSESSMENT OF NUTRITIONAL STATUS AbdelazizElamin, MD, PhD, FRCPCH College of Medicine Sultan Qaboos University, Oman 6. ASSESSMENT OF NUTRITIONAL STATUS Frontline laboratory Network The American Journal of Clinical Nutrition. www.frontlinelabs.com 7. Nutrition programme – unit 5www.egyankosh.ac.in/bitstream/123456789/35622/.../Unit%2025.pdf